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h , <br /> 3AP LI CATION FOR PERMIT <br /> SAN JOAQUIN COUNTY `pIlBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 0 <br />.{ 1601 E. HAZELTON AVE. , PHONE_ (209)468-3420, <br /> - P <br /> O BOX 2009, STOCKTON, CA 95201 <br /> Pp iT 'RXFIRES 1 YEAR FROK DATE ISSUED <br /> (Complete in Triplicate) _ <br /> f: p <br /> Application isAby made,to San Joaquin County for a permit to construct and/or install therk herein described._, This <br /> appllcatioq is leads in casepliance with San Joaquin County Ordinance No. 549 and 1862 and the Rues and#Rogulat;ions of Sang <br /> in County Public Health Services. <br /> - '" <br /> Joaquin <br /> �. City Lot Size/Acreage � "S0ibft <br /> Address' <br /> r' t <br /> tAddress - ^Phone <br /> 1 r�n.r.� Address License No. r ,`,f'Fton <br /> CenittiEfor �, <br /> LL/PUMP: NEW WELL ❑ WELL REPLA MENT ❑ D. STFtUCTION Out of Service W111 <br /> ❑ <br /> PUMP INSTALLATION.O SYSTEM REPAIR O OTHER Monitoring 11 ❑ <br /> j At E TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO: PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/sumps, <br /> INTENDED USE` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � (� <br /> _._ C7 <br /> ❑ Indust ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dis. dN Well Casing <br /> Cl DomeziticlPriyite 0 Gravel Pack 0 Tracy Type of Casing cions * , <br /> I'1 Public n Other i Il Delta J)*Wh of Grout Seal tie (Grout <br /> I I Irrigatfon" . —Approx.Depth a i 1 Eastern Surface Seallrtstilled by <br /> Repair Vyork 0one- U Type of Pump H.P: State Work Done <br /> Well Destruction 'r ❑ Well Diameter Sealing Material i'Depth <br /> r.Depth <br /> 1►STIti"r Materi"' th -_..._._.. <br /> TYPE OF SfiIFMW I¢ l INSTALLATION I V471PERA1,144ADDITION;R DESTRUCTION I 1 1N6 tam Rerm ed it public sewer is <br /> `! avaita hMl n <br /> InstallitWii�%4 tom"' 1? t Commercial <br /> Nur»bgr df, vin uta _,,,fix`Number of pedrooms { ` <br /> Character of sq'rilto a df �4 S feetr� '` ,• ° Wetp(�table depth) <br /> SEPTIC TANKr [�, ,, Capacity — tef`t`t►mpartments � <br /> 3, a f n R `MetflOd Of Disposal <br /> PKG. TR(A N . PLT C7 t <br />' FondPrsPerty Lls� lisance to <br /> LEACHIf 4-UME o. b Length of lir** Totall length/size .— <br /> FILTEA E}EEi` CI Distancd to nearest; Wer Foundai{dn. Props L rM <br /> Ry <br /> SEEPAGt"PITS t I Depth , Size 'Num30r <br /> i SUMPS Ll Distance to� Well foundation Property LI ='— <br /> DISAk`PONDS 1 have rs thisa licatidn and th`' work wilibe done in,accordanrie with Sari Joeiquin nty dinar►ces, to saws, and <br /> rules and regulations of the San Joaquin .County 3 1` <br /> Home owner or 11COPSed agent's bignature codifies the following: "F conifyl that in the performance-gf the..work for which this permit is:issued, I shall not <br /> employ etly persona auch maryhe�ar as tp becoma'subject toworkmeri's com""neat on"1'aws`of California. ContiBctor's hiring a sub ontracti09 signature <br /> certifies tbs foo :"t eertify'that in t6a performance of tke work for whiclf this,0 rp4 is issued.t:st�ti�r►pkW perear►asuhjhct to w4�kmar�i,compenss <br /> „ , <br /> tion Iswslof Calif�r ,ta �- ._.• * <br /> The appl ant r ON r in tt s. Complete drawing on reverse side. r <br /> a <br /> .! <br /> Signed 1" Title: Date: <br /> 6RAATiit>c -USE ONLY, <br /> IT14 1, <br /> Application A y i7aLe Area 13 <br /> PP I y <br /> Pit or Gr6ut Date Final Inspection by': T Date <br /> ZO%QO <br /> �.- I„anact�,n by <br /> Addhlono Corsyn,sr <br /> Appl t 04 copf„es toI San Joaquin County Public Health <br /> Services, Havironmental Health Permit/Services " <br /> g 1601 It. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 "< <br /> FEE AN HINT DUE AMOUNT REMITTED CASH RECEIVED BY QAT PEAMITNO. <br /> INFO <br /> . EH 13.24(Rft 1i115) � ..� � ' l .. (lj�t'F.1 7 I F'l„, G/• too <br /> EH tt•Za <br />